Oesophageal perforation is a fulminating and potentially fatal lesion. Therefore, early recognition and treatment is the most important factor in its management.[1] Blunt thoracic trauma rarely results in oesophageal injuries and hence the diagnosis is often missed initially. We are presenting one such case, with emphasis on early diagnosis and aggressive treatment.

A 25 year old male patient was admitted to our hospital 24 hours after a vehicular accident. Immediately after the accident, he had been admitted to a small peripheral hospital where he was kept under observation, but was subsequently transferred Ito our hospital because of incessant retrosternal pain. He was slightly pale and breathless. Pulse was 112/minute and the respiratory rate, 26 per minute. He had friction burns on his back. Examination of the chest showed diminished air entry on the base of the right lung. There was no evidence either of surgical emphysema or of fracture ribs. The patient did not have any other injuries. Arterial blood gases showed PO2 of 56 mm Hg and PCO2 of 32 mm Hg; haemoglobin was 10 g% and PCV of 32.Plain X-ray of the chest showed pneumomediastinum, widened mediastinal shadow and a small pleural effusion on the right side [Figure - 1]. An oesophageal tear was suspected and a contrast oesophagogram performed. This showed the dye trickling from the oesophagus into the right pleural cavity at the level of the 8th thoracic vertebra [Fig. 2 ]. Thus the diagnosis was confirmed. The patient was prepared for surgery. An intercostal drain placed in the right pleural cavity drained 350 ml fluid. A feeding gastrostomy and defunctioning cervical oesophagostomy were also done. The distal end of the oesophagostomy was blocked with vaseline to prevent further mediastinal contamination by oropharyngeal secretions.In the post-operative period, the patient was given gentamicin and penicillin for 5 days and then cephalosporin for further 10 days. The choice of the antibiotics was based on the sensitivity pattern of the organisms grown from the intercostal drain. It was noteworthy that these organisms were the same as those grown from the saliva i.e. Klebsiella. The patient was nursed in a sitting position to prevent regurgitation of gastric contents. After 48 hours, he was given gastrostomy feeds which were gradually increased so as to give him 5000 calories and 100 g of proteins daily.Contrast oesophagogram done after 3 weeks revealed a small localised cavity at the site of perforation (see [Fig. 3] and after 5 weeks showed a nearly normal oesophagus. At this stage he was given oral feeds. He was also taught self-bouginage of the oesophagus with gum-elastic bougie. This was initially done through the cervical oesophagostomy and later orally. The intercostal drain and the gastrostomy tubes were removed. The cervical oesophagostomy gradually narrowed and was closed after 3 months.The patient now regularly dilates his oesophagus and over the last 6 months has had no complaints.

(A) Mechanism of injuryStothert et al[4] have reviewed 17 cases of oesophageal and tracheal injuries following blunt thoracic trauma and have postulated two mechanisms for the injury: (i) The rupture occurs due to raised intraluminal pressure from abdominal compression in the presence of a closed glottis.(ii) It may be due to compression of the oesophagus between the sternum and the vertebrae. Rib fractures are unusual and the universal occurrence of this process with a compressible rib cage supports this hypothesis. It thus usually occurs in young adults.(B) DiagnosisThe clinical features are frequently delayed and a high degree of suspicion is necessary to establish the diagnosis. The features that may be present are-(1) Retrosternal pain (2) Tachypnoea(3) Surgical emphysema in the absence of fracture ribs(4) X-ray chest showing pneumomediastinum.Contrast oesophagogram with water soluble dyes (Conray 420 or Gastrograffin) should be done in all suspected cases.(C) ManagementDifferent methods have been tried for the treatment of oesophageal injuries.[2], [3] We advocate drainage of the appropriate cavity with near total exclusion of the thoracic oesophagus by cervical oesophagostomy and gastrostomy.[6]The cervical oesophagostomy prevents further mediastinal contamination by saliva which is the main source of organisms causing mediastinitis. This was noted in this case, as the organisms grown from the intercostal drain were similar to those grown from the saliva. The cervical oesophagostomy is also useful for oesophageal dilatation and for doing contrast oesophagograms.The gastrostomy initially decompresses the stomach and prevents reflux of gastric contents into the torn oesophagus. Later it is used for hyperalimentation.Primary suturing of the oesophageal tear is not advocated as there is marked contusion of the oesophagus around the tear. Further, due to the delay in treatment, the edges of the tear are oedematous and friable.